Health Information Management

Q/A: Assigning modifier -52 for cancelled procedures

APCs Insider, March 16, 2012

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Q: Our radiology department has begun billing for cancelled diagnostic procedures. For example, a provider cancels a test for a specific reason (e.g., the patient is in too much pain to undergo an x-ray). Radiology staff members are appending modifier -52 (reduced service). I thought modifier -52 is used to indicate that a test performed is less than that described by a CPT® code when there isn’t another code to report. Has something changed?

A: CMS noted in the January update to OPPS, Transmittal 2386, that it updated the guidance regarding modifiers for discontinued services effective January 1. Since 2005, guidance concerning modifier -52 included “partial reduction or discontinuation of services for which anesthesia is not planned.” The updated language for modifier -52 now includes this language: Modifier -52 is used to indicate partial reduction, cancellation, or discontinuation of services for which anesthesia is not planned.

The guidance states: Modifiers provide a way for hospitals to report and be paid for expenses incurred in preparing a patient for a procedure and scheduling a room for performing the procedure where the service is subsequently discontinued.

Documentation in the medical record must contain specific information about medical necessity that led to cancellation or a reduced service. This documentation is crucial to support the resources being reported and to document the clinical/medical reason that necessitated cancellation of the service.

Cancellation is elective and the service is not reportable if a patient arrives but decides not to undergo the scheduled test or if a patient doesn’t arrive for a scheduled test.

Refer to the Medicare Claims Processing Manual, Chapter 4, §20.6.4..

Editor’s note: Andrea Clark, RHIA, CCS, CPCH, chairman, CEO, and founder of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.



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